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There are no such eligibility criteria, any individual can fill out the form.
Do you have any allergies?
Do you have any medical conditions that require immediate attention?
Have you ever had an allergic reaction to a vaccine?
Do you have any chronic conditions? If so, please briefly describe below.
Are there any changes that should be made for future vaccines or treatments?
Have you ever had any adverse reactions to medications or treatments? If so, please briefly describe below.
Do you have a current prescription for any medication?
If yes, please list the name of each medication:
Are there any changes that should be made for future vaccines or treatments?